Issue link: https://beckershealthcare.uberflip.com/i/324690
57 Executive Briefing: Population Health Management Get your free analytics eBook. Visit optum.com/gamechange to download the new eBook, Moneyball Analytics, and begin changing your game. Get in the analytics game. We understand health care analytics can be intimidating. But with the right data and processes, analytics have the potential to change the game for health care providers. From reducing costs to improving health outcomes, a smarter game plan founded on the right data and analytics can create a winning combination for providers and patients across the care continuum. Optum is a leading information and technology-enabled health services business dedicated to helping make the health system work better for everyone. With more than 50,000 people worldwide, Optum delivers intelligent, integrated solutions that help to modernize the health system and improve overall population health. Using natural language processing to analyze echocardiogram results, for example, renders notes on ejection fractions struc- tured and reportable, allowing physicians to better gauge the risk of their patients with congestive heart failure. That same technol- ogy can also enhance the capture of symptom and pulmonary function test results, extracting reportable data points. This can give physicians exceptionally sharp focus on the clinical status of patients with COPD. The Mayo Clinic Health System is piloting a congestive heart fail- ure predictive model that brings together in-depth clinical, diag- nostic and demographic data to identify patients at highest risk for admission within the next six months. Mayo Clinic users review and export lists of these patients for outreach and coordination. They can then track the impact of this work by comparing bench- mark hospitalization rates for the congestive heart failure popula- tion to the true outcomes for the coordinated population. In addition to identifying and acting on gaps in care, organizations can use analytics to track clinical, operational and financial per- formance. Dashboard reports, for instance, can provide valuable insight into clinical performance, laying the groundwork for initia- tives designed to promote physician practice of evidence-based medicine and drive improvements in quality, safety and efficien- cy. Gaining access to comprehensive longitudinal data can also help providers benchmark their practices against other practices across the country. Stratify patients by risk to more effectively coordinate care Segmenting a patient population lays the groundwork for devising effective care management and patient engagement programs. Many organizations have retooled their care management ap- proach from a reactive model to one that is driven by predictive, proactive intervention and care. Mid Hudson Medical Group in New York, for example, is using a clinical intelligence platform to identify high-risk patients with dia- betes and focus its care coordination efforts to improve disease management. After analyzing its data, Mid Hudson was able to identify which of its diabetic patients met criteria for proactive outreach. The group was able to single out patients whose HbA1c was greater than 7 percent at their last visit, or who had not been seen by a provider within the last 12 months. As a result, about a third of such pa- tients were seen one or more times within the first eight months of the program. In this group of diabetics, one-third achieved an HbA1c level of less than 8 percent, and 60 percent of those with HbA1c higher than 9 percent became more intensively managed through more frequent visits with their primary care physician. Yet another group, the Billings Clinic in Montana, has implement- ed a scalable approach to identify and track patients with hyper- tension. By applying analytics to its data, the clinic was easily able to find patients with hypertension based on clinical findings such as blood pressure readings. It was also able to stratify pa- tients with hypertension into clinically relevant cohorts based on clinical findings, such as those consistent with kidney disease or diabetes. Billings was then able to further analyze these groups by clinical acuity, medication patterns or other process measures. The provider group went on to monitor the impact of its hyperten- sion interventions over time and track its patients' control longitu- dinally. Physicians were also provided with reports that compared their results to their peers locally and at other leading practices throughout the U.S. Use advanced analytics to prepare your organization for value-based care Providers who use population health management principles to care for their patients with chronic conditions will be ahead of the curve as the industry continues its march toward value-based reimbursement. Leveraging advanced analytics to create more comprehensive risk profiles for patients with complicated illness- es will better position providers to make the transition from treat- ing illness to managing health. n The Mayo Clinic Health System is piloting a congestive heart failure predictive model using in-depth clinical, diagnostic and demographic data to identify patients at highest risk for admission within the next six months. Many organizations have retooled their care management approach from a reactive model to one driven by predictive, proactive intervention and care.